Health Promotion

Another Reminder That All Measures Matter

By: Paul H. Dworkin, MD and Erin Cornell, MPH

In April of 2017, we published an Advancing Kids blog entitled, “An Impressive Reminder That All Measures Matter”.  In that blog, we cited a recently published article that we believed validated our approach to measuring the impact of our efforts.  We noted that Connecticut Children’s Office for Community Child Health (Office) embraces the use of proximate measures to expand our capacity to assess the impact of developmental interventions such as Help Me Grow. Our work focuses, albeit not exclusively, on measuring the extent to which we are strengthening protective factors to enable families to better support their children’s healthy development. Despite the importance of this approach, we acknowledged that we are mindful of the inherent limitations of employing proximate measures to support the long-term, highly desirable outcomes we ultimately seek, which are children’s optimal health, development, and well-being. Therefore, to complement our use of proxy measures to assess the impact we are having on family-level protective factors, we also seek the capacity to build a broader set of measures at the community and system levels to capture our impact across the early childhood spectrum. Such efforts ensure that we adopt a comprehensive approach to measurement that offers a variety of lenses through which to view our impact.

We concluded the blog by noting that our innovations in early childhood seek to strengthen families and systems, and so our measurement approaches reflect this. While we continue to embrace protective factors as key proxy measures, we recognize the need to also pursue long-term efforts to measure developmental and other outcomes. Also, with reference to the specific study cited in the blog, our focus on family capacity and functioning does not minimize the importance of examining impressive and sophisticated biological (e.g., anatomical, cellular, and physiological) measures and markers. We increasingly recognize that with respect to evaluating our impact on children’s optimal health and development, all measures matter.

A recently published article in the journal Pediatrics reinforces the relevance and validity of our ever-evolving approach to measures and metrics.1 Our friends and colleagues at the Centre for Community Child Health of The Royal Children’s Hospital in Melbourne, Australia, led by Sharon Goldfeld, conducted a randomized trial of nurse home visiting for families experiencing adversity. The researchers tested the effectiveness of an Australian nurse home visiting program, right@home, offered to pregnant women experiencing adversity. Outcome measures were improvements in parent care, responsivity, and the home learning environment. Compared with women in the control group, those receiving the intervention reported more regular child bedtimes, increased safety, increased warm parenting, less hostile parenting, increased parental involvement, and a greater variety of experiences in the home environment. The researchers concluded that the right@home program improved parenting and home environment determinants of children’s health and development.

While we are always pleased to learn of new studies that validate the impact of such early childhood programs as high quality nurse home visiting, we are particularly excited by the researchers’ selection of measures and the extent to which they confidently relate the impact of such measures to children’s outcomes. The researchers’ aim was to test whether the right@home program “…could be used to improve outcomes in domains related to parenting and the home environment that are known to predict beneficial child developmental trajectories.”  Their use of measures known to predict later, highly desirable outcomes is consistent with our application of proximate measures. In our prior blog, we noted our growing knowledge of the positive impact of several Office programs on protective factors, those variables such as concrete support in times of need, that predict later positive outcomes in family well-being. We are encouraged that the Australian researchers adopted a similar approach in employing outcome domains of parental care, responsivity, and the home learning environment as predictors of future child outcomes. Our focus on protective factors employs the very same logic.

Despite the importance of this approach, we remain mindful of the inherent limitations of employing proximate measures to suggest the long-term, highly desirable developmental outcomes we ultimately seek. Goldfeld and colleagues similarly acknowledge the “…trade-off between waiting for the children to be old enough for reliable direct developmental assessment and publishing findings” and commit to later perform direct assessments of child development, including measures of learning and literacy, executive function and attention, social and emotional well-being, among others. We have similarly noted the “…the need to continue to pursue long-term efforts to measure developmental and other outcomes.” The limitations of relying on proximate measures can be addressed by leveraging several best practices from the measurement field, including, for example, choosing proximate measures that are reasonably presumed to be strongly linked to the program in question, and for which there is not high potential for the proximate measures to be more directly influenced by other factors. In the case of the right@home study, it is reasonable to expect that the activities associated with the home visiting program could have strong and direct influences on proximate measures such as variety of experiences in the home environment.

The Australian researchers conclude that their study proves that “…interventions can be effectively delivered within existing services to reduce the impact of social and environmental factors predisposing children to inequitable outcomes.” We have similarly concluded that research studies conducted in Connecticut and Utah that demonstrate how the Help Me Grow model strengthens families by enhancing protective factors is efficacious in promoting children’s optimal development.2,3   We see opportunity to continue to build on this emerging evidence in future evaluations of the Help Me Grow model. Indeed, this study again reminds us that, with respect to evaluating our impact on children’s optimal health development, all measures matter.


1 Goldfeld S, Price A, Smith C, et al. Nurse home visiting experiencing adversity. A randomized trial.  Pediatrics 2019;143(1):e20181206.

2 Hughes M, Joslyn A, Wojton MM, O’Reilly M, Dworkin PH.  Connecting vulnerable children and families to community-based programs strengthens parents’ perceptions of protective factors.  Infants Young Child 2016; 29(2): 114–127. doi: 10.1097/IYC.0000000000000059.

3 Hill KD, Hill BJ.  Help Me Grow Utah and the impact on family protective factors development.  Journal of Children’s Services; 13(1): 33-43,

Paul H. Dworkin, MD is the executive vice president for community child health at Connecticut Children’s, the director of Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow National Center.  Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine.  Learn more »

Erin Cornell, MPH, is the associate director of the Help Me Grow National Center which is a program of Connecticut Children’s Office for Community Child Health.

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